When no cause can be found

Ola H. Skjeldal About the author

Examination and treatment of children and adolescents with functional disorders calls for interdisciplinary collaboration and good communication with patients and their relatives.

The case history presented by Gjems & Helgeland in this issue of the Journal of the Norwegian Medical Association concerns a boy with headache and paralysis for which no organic explanation could be found (1). Psychiatric assessment also revealed no signs of a mental disorder, and it was therefore unclear who should be responsible for the boy’s further treatment. The patient and his parents were left with unanswered questions and an intense fear that the boy had a serious illness. Only when an interdisciplinary, collaborative working group was finally established was it possible to achieve a therapeutic situation which succeeded in enabling him to recover.

The term ‘functional disorders’ or ‘conversion disorders’ is a collective term to describe symptoms and findings for which medical examinations fail to determine any organic causal explanation (2). No reliable studies of prevalence are available, but sub-studies indicate that conversion disorders in children and adolescents occur regularly (3). It is therefore probable that many doctors will encounter these patients in the course of their careers.

It is frequently in the field of paediatrics that the most serious and dramatic courses of functional disorders are observed (4). This is not surprising, as children and adolescents tend to express conflicts and difficulties through physical symptoms more often than adults (5). These may be short-lived and resolve on their own, but they can also persist and be difficult to treat. The disorders are most frequent in children in the 12–15-year age group and are more commonly found in girls than in boys (5).

Children and adolescents with functional somatic disorders have a wide range of symptoms and findings, and these are most often neurological. This places high demands on the experience of the paediatrician or neurologist. The clinical examination is crucial and will form the basis for further examinations. It is imperative to devote sufficient time to this, and to be able to explain and inform. The message that no organic explanation can be found may otherwise easily be perceived as distrust regarding the patient’s symptoms. This may give rise to unnecessary alarm and not infrequently contribute to anxiety and fear of serious illness on the part of the child and the parents, as Gjems & Helgeland point out. This situation is not improved if a psychiatric assessment concludes that the patient does not meet the criteria for a paediatric mental health diagnosis. This results in the family being referred back and forth in the system, and sometimes in the parents seeking out unscrupulous pseudomedical practitioners.

Collaboration on patients across the healthcare professions may be beneficial but is not always easy to achieve. There are several reasons for this. The working day is hectic and busy, and interdisciplinary activities are often not the first priority. A lack of knowledge and respect for the expertise of other specialties also plays a role, and the lack of a holistic understanding of the patient’s situation certainly also contributes. It is not unusual for the patient to lose out in this, with a poorer diagnostic assessment and treatment.

Interdisciplinary collaboration is something we must strive for. Proper treatment for this group of patients entails creating secure frameworks and a predictable structure. This also includes establishing good interdisciplinary connections and good collaboration around the patients. The core of the treatment programme for children and adolescents with functional disorders lies in communication between the professionals involved. This was pointed out as early as 1994, when it was claimed that these patients would profit from close collaboration between various professional groups (6).

For several decades, Oslo University Hospital has used a working method whereby child psychiatrists and child psychologists collaborate closely with paediatricians. This ensures a proper exchange of knowledge and understanding of each other’s work culture. In recent years, the understanding that this type of collaboration is essential for this patient group has fortunately gained a firmer foothold. In 2007, the Directorate of Health’s status report stated that ‘within the health sector, the greatest barrier for children and adolescents needing coordinated services is the absence of coherence, predictability and coordination of the services’ (7). We faced the consequences of this. As late as 2016, the decision was adopted in the National Health and Hospital Plan that all child and adolescent medical departments should include psychologists and/or psychiatrists (8).

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